This project assesses the safety and efficacy of pharmacological and behavioral treatments of opioid dependence in HIV-infected patients and assesses methods for decreasing high risk HIV transmission behaviors in substance abusers. The AIDS epidemic has rapidly extended to injection drug users, many of them dependent on opioids; these patients represent a challenge to the health care system, as they require medical care and hospitalization for chronic medical disorders. Withdrawal syndromes represent added stresses that may negatively affect the outcome of medical treatments in compromised patients. In the past year we completed a randomized, double-blind clinical trial to evaluate and compare the effects of three medications for opioid detoxification on withdrawal and pain scores in AIDS patients hospitalized for an acute medical condition. Standardized and self-reported and observed measures of opioid withdrawal, a choice of pain faces and visual analogue scales for pain and for desire/craving for heroin were collected over a four-day treatment period. Mean withdrawal scores and mean pain ratings decreased from intake and to the fourth day of treatment. There were no statistically significant differences in treatment efficacy between the groups. Overall, buprenorphine, clonidine, and methadone were equally effective for treating opioid withdrawal in medically ill patients. Forty-five percent of patients also received additional morphine. In post-hoc analysis, these patients reported more pain symptoms during treatment, in spite of lower pain scores at intake. Thus, in a subset of patients, opioid detoxification appeared to interfere with pain treatment. A second study is under way to examine whether sustained HIV protective behavior can be achieved by adding a cognitive-behavioral coping skills and relapse prevention intervention to voucher-based contingency management. In a randomized clinical trial with inner city methadone-maintained cocaine-dependent subjects, patients will be taught self-control skills: 1) to increase non-drug sources of reinforcement to compete with reinforcing effects of drug use; and 2) to develop adaptive problem-focused and emotion-focused coping responses to manage drug specific and general life stressors related to drug use and HIV risk transmission.